New York Dressage Ltd
Name______DOB______Height______Weight______
Address______City/State______Zip______
Home Phone______Work Phone______
Cell______Email______
What special information should the instructor know for a safe and enjoyable riding experience? (Allergies, conditions that affect the student’s response time or ability to follow instructions, physical limitations etc.)
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Student has ridden: 0-2 times_____3-5 times_____6-8 times______9+ times______
Student has ridden: English______Western______I don’t know______
Student has: Walked______Trotted______Cantered______Jumped______
Student has previously had riding lessons: Yes______No______
If Yes, when and where? ______
Responsible Party/Emergency Contact Information
Name______Relationship______
Phone______Address______
Medical Release
If an emergency occurs or in the event of an accident, injury or illness and I (we) cannot be contacted, I (we) do allow our self (our child) to be treated by emergency personnel, a physician, a hospital or other certified medical personnel.
Signature______Date______
2015 Waiver and Release of Liability
This WAIVER and RELEASE of LIABILITY is made and entered into on this day of ______2015, by and between New York Dressage Ltd ______as Rider, and, if Rider is a minor, Rider’s parent or guardian, ______(collectively “RIDER”). In return for the use, today and on all future dates of the property, facilities and services of Kimberlee Martin/, the RIDER, his/her heirs, assigns, and legal representatives, hereby expressly agree to the following:
1. Inherent Risks: There are significant elements of risk in any adventure, sport, or activity associated with horses; horse drawn equipment and/or saddle animals including but not limited o horses, mules and donkeys (referred to herein as “activity”) and the use of any equipment therewith. The undersigned acknowledge(s) there are inherent risks associated with equine activities such as participating in such activities, The inherent risks include, but are not limited to the propensity of equines to behave in ways such as running, bucking, biting, kicking, shying, stumbling, rearing, falling or stepping on, that may result in an equine’s reaction to such things as sounds, sudden movement, and unfamiliar objects, persons or other animals; certain hazards such as surface and subsurface conditions, collisions with other animals; the limited availability of emergency medical care; and the potential of a participant or others, such as failing to maintain control over the animals or not acting within such participant’s ability.
2. RIDER acknowledges that horses, by their very nature are unpredictable and subject to animal whim, which may include behavior including, but not limited to their propensity to kick, bite, shy, buck, stumble, bolt, rear or general unpredictability. RIDER assumes all risks in connection therewith, and expressly waives any claims for any injury or loss arising there from.
3. RIDER agrees to abide by and follow New York Dressage Ltd. rules and regulations which shall by posted and/or available from time to time.
4. RIDER further acknowledges that the behavior of any animal is contingent to some extent upon the RIDER. RIDER shall assume risks therefore and warrants that a full and fair disclosure of RIDER’s abilities has been made to Kim Martin.
5. RIDER agrees to hold New York Dressage Ltd/ and all of its successors, assigns, subsidiaries, affiliates, officers, directors, employees and agents completely harmless and not liable and release them from all liability whatsoever and AGREES NOT TO SUE them on account of or in connection with any claims, causes of action, injuries, damages, cost or expenses arising out of RIDER’s use of or present upon New York Dressage Ltd./property and facilities, including without limitation, those based on death, bodily injury, property damage, including consequential damages, except if the damages are caused by the direct, willful and wanton negligence of Kim Martin/.
6. RIDER agrees to indemnify and defend Manager against, and hold it harmless from, any and all claims, causes of action, damages, judgments, costs or expenses, including attorney’s fees, which in any way arise from the RIDER’s use of or presence upon the Manager’s property and facilities.
7. In the event RIDER is using RIDER’s own horse, or a horse(s) not owned by New York Dressage Ltd. /, RIDER warrants said horse(s) shall be free from infection, contagious or transmittable diseases. NYD/ reserves the right to refuse access or use of any horse upon the premises that does not appear to New York Dressage Ltd. to be in good health, or is deemed dangerous or undesirable.
8. RIDER agrees to waive the protection of any applicable statutes in this jurisdiction whose purpose, substance and/or effect is to provide that a general release shall not extend to claims, material or otherwise, which the person giving the release does not know or suspect to exist at the time of executing said release.
9. All Minors are required to wear a helmet while mounted. No children are to ride on from of saddle with parent.
WARNING
Under New York State law, an equine professional is not liable for an injury to or the death of a participant in equine activities resulting from the inherent risks of equine activities pursuant to the Revised Statutes of New York
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RIDER Signature and Date:
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Parent or Guardian signature if RIDER is a Minor and date: